Background Research shows that more than 30% of hospital inpatients over 85 may die within the next year. Advance Care Planning (ACP) has been shown to increase achievement of preferred place of death and decrease unnecessary hospital admissions in the last year of life. Accordingly, local Elderly Care discharge summaries include a mandatory ACP section. As part of the ‘Building on the Best’ quality improvement programme, our Trust is focusing on improving handover of ACP information as people move between healthcare settings.

Aims To determine best practice in sharing information on ACP between hospital and community services

To review current transfer of information about ACP on discharge from an Elderly Care ward.

Method We reviewed relevant literature about transfer of information on discharge summaries and retrospectively audited 30 discharges from an elderly care ward. We recorded inclusion of key ACP topics, such as cardiopulmonary resuscitation status and preferred place of death, as well as deaths within the subsequent six months.

Results Literature review highlighted importance of high quality information in discharge summaries to decrease inappropriate readmission in last year of life. No discharge summaries audited included any information in the ‘mandatory’ ACP section

50% documented DNAR status separately

53% of patients were readmitted to our hospital within six months

30% died within six months.

Conclusion Although a significant proportion of patients on elderly care wards are in the last year of life, there was minimal sharing of ACP information with community services. The ‘process’ change of including a mandatory ACP section on discharge summaries has not improved outcomes. Future quality improvement will focus on staff engagement and raising awareness of the importance of ACP. We have developed a blended learning programme to support the implementation of routine identification of patient in their last year of life in multi-disciplinary meetings, thereby triggering ACP and communication across organisations.